Make sure patients are appropriate for home care

Caregivers should understand what's required

In today's health care environment, case managers are under more pressure than ever to discharge patients from acute care; but before you send patients home with home health care, home medical equipment, or hospice services, make sure that they are appropriate for those services, advises Elizabeth Hogue, Esq., a Washington-DC based attorney specializing in health care issues.

This means that the patient's home must be safe and able to accommodate the patient and that the patient can care for himself or has a caregiver, she adds.

"As inpatient stays become shorter, referrals for post-acute services are increasingly frequent and can improve the quality of life for patients; but the idea that all patients who do not have another source of care should be referred for these services is definitely risky business," Hogue says.

Provision of services to patients at home when they cannot care for themselves and have no primary caregiver greatly enhances the risk of legal liability, she notes.

"It is also likely to violate the important ethical principle of justice, which dictates that all patients are entitled to appropriate care," Hogue says.

Make sure services are appropriate

Home care providers usually can meet the clinical needs of patients in their home, but case managers need to make sure the patients are appropriate for the services, she says.

Patients who are appropriate for post-acute services in the home must either be able to care for themselves or they must have a paid or voluntary caregiver available to meet their needs in between home health or hospice staff visits.

In addition, their home environments must support home health services and the services they need should be the type that can be provided in the home, Hogue says.

It may be difficult for case managers to evaluate patients' home environments without going to visit them, but they can evaluate whether patients are likely to be able to care for themselves and if they have friends or relatives who are willing to serve as the primary caregivers, she adds.

Before you make referrals for home health services, make sure that the patients thoroughly understand that the care they receive in the home will not be like the care they get in the hospital and that they will need assistance much of the time.

"Unlike hospital care, there is a crucial role for primary caregivers to play when patients receive home health or hospice care. This role must be made clear to patients and primary caregivers before referrals are made for these services," Hogue says.

Be as specific as possible about the role of primary caregivers, Hogue advises.

For instance, help them understand the tasks they will be expected to perform and realistically evaluate whether they can handle them. For instance, if a patient will need assistance with transfers, someone with back problems may not be appropriate for the role.

"Some caregivers may be reluctant to care for incontinent patients, to dress wounds, and give injections. To make the referral a success and ensure that the patient will receive the care he or she needs, they need to know in advance exactly what is expected of them," Hogue says.

Case managers also should make it clear that the role of the primary caregiver is likely to change over time as the patient's condition either improves or deteriorates further.

If it appears that the patient's condition is likely to deteriorate or he or she will need care at home for an extended period of time, be sure that the caregiver understands.

"If patients cannot care for themselves at home in between visits from home care and hospice staff and they cannot identify a voluntary or paid caregiver, they should not be referred for services in the home," Hogue adds.

This is especially true when case managers know that patients need institutional care but they refuse the care.

"Patients have an absolute right to refuse services, but this does not mean that home health, home medical equipment, or hospice providers must provide services in inappropriate settings," she says.

Case managers should communicate complete and accurate information to post-acute providers to ensure that they are able to provide the care that patients need, Hogue adds.

In some cases, home health, home medical equipment, or hospice care providers may say they cannot accept patients because they would be unsafe at home, she points out.

Patients may live in a place that is in disrepair, putting both patients and caregivers at risk, or the homes may be infested with roaches or rodents. Patients may suffer repeated falls at home that make it risky for them to remain there.

Home care providers often encounter barriers to care that hospital-based case managers can only imagine. Unsafe neighborhoods or unfriendly pets are among them, Hogue says.

When a home care provider states that patients can't be cared for at home, case managers should find out specific reasons, she says.

Patients who are sent home too quickly and too sick are risky for home health agencies to accept, Hogue points out.

"When discharge plans are inappropriate and lawsuits result, post-acute providers may be drawn into these lawsuits despite the fact that the basic problem was breach of duty by case managers," she says.

Be especially careful with patients who are discharged on Fridays, Hogue says.

She cites a study presented at a National Association of Home Care conference that showed that patients who are discharged from the hospital to home care on Fridays are significantly more likely to be rehospitalized within a week than patients discharged on other days of the week, Hogue says.1

"The reasons for this disparity remain unclear. Regardless of the explanation, these data spell potential trouble for hospital discharge planners and case managers. If a patient is discharged on Friday and requires hospitalization later, a jury could conclude that the discharge planners were just too eager to 'clear the decks' before the weekend to the detriment of patients," she says.

(For more information, contact Elizabeth Hogue, Esq., e-mail:


  1. "Data Analysis Exercise: Beware of Friday's Child." Home Care Automation Report, Oct. 31, 2006.